Diabetes

Notes for newly diagnosed Type 2 Diabetes Mellitus

History

Symptoms

  • Glycosuria

  • Hyperglycemia

Predisposing

  • Age

  • Family history

  • Cultural group (higher risk – Aboriginal and Torres Strait Islanders, South Pacific Islands, Southern Europe, Eastern Europe and Central Asia, the Middle East, North Africa and Southern Asia)

  • Overweight

  • Physical inactivity

  • Hypertension

  • Gestational diabetes, or a history of large babies

  • Medications causing hyperglycaemia e.g., antipsychotics, corticosteroids

  • Personal or family history of haemochromatosis

  • Auto-immune diseases

Risk factors for complications

  • Personal or family history of cardiovascular disease

  • Hypertension

  • Smoking

  • Dyslipidaemia

  • Lifestyle issues

  • Smoking

  • Nutrition

  • Alcohol

  • Physical inactivity

  • Occupation

General symptom review including

  • Cardiovascular symptoms

  • Neurological symptoms

  • Bladder and sexual function

  • Foot and toe problems

  • Recurrent infections, particularly urinary and skin

  • Vision

Examination

  • BMI and waist circumference

  • Cardiovascular system:

    • Blood pressure, lying and standing

    • Peripheral and neck vessels

  • Eyes:

    • Visual acuity (with correction)

    • Cataracts

    • Retinopathy (examine with pupil dilation)

  • Feet:

    • Sensation and circulation

    • Skin condition

    • Pressure areas

    • Interdigital problems

    • Abnormal bone architecture

  • Peripheral nerves:

    • Tendon reflexes

    • Sensation:

      • Touch (10 g monofilament)

      • Vibration (128 Hz tuning fork)

  • Urinalysis:

    • Albumin

    • Ketones

    • Nitrates and/or leucocytes

Investigations

  • Baseline:

    • Renal function – eGFR, urinary albumin creatinine ratio (ACR)

    • Lipids – LDL-C, HDL-C, Non-HDL-C, total cholesterol, triglycerides

    • HbA1c

  • Also consider:

    • ECG if patient aged > 50 years and ≥ 1 other vascular risk factor

    • TSH if there is a family history or clinical suspicion of thyroid disease

Cardiovascular

Management

Consider seeking urgent advice if

  • Persistent or severe hyperglycaemia (> 20 mmol/L)

  • HbA1c > 97 mmol/mol (11%)

  • Presence of ketonuria or ketonaemia (> 0.6 mmol/L)

  • Severe hypoglycaemia requiring third party assistance

  • Frequent hypoglycaemia (3 or more hypoglycaemic episodes per week)

If pregnant and diabetic, escalate care

Explanation of diabetes

Healthy Eating

Increased physical activity

  • Advise patients to:

    • aim for 30 minutes of moderate intensity physical activity such as brisk walking on most days.

    • increase activity time to 60 minutes per day, when possible.

    • reduce inactivity and avoid sitting for extended periods e.g., TV watching (even standing uses more energy).

  • Help the patient find an activity that fits in with their lifestyle and is sustainable. Undertaking physical activity with others is often more enjoyable.

  • Any increase in activity, however small, is a positive step. "Snacks" of activity, for example 3 x 10 minutes daily may have some value.

  • Provide patients with a Diabetes Australia Physical Activity fact sheet.

Weight reduction

  • Weight reduction is an important target for most people with diabetes or prediabetes.

  • Most people achieve weight loss after following healthy eating guidelines and increasing exercise.

  • If the patient is overweight or obese, aim for a weight loss of 0.5 to 1 kg per week and a long-term loss of 5% of initial weight – but acknowledge any degree of loss as a success.

  • Staying the same weight may be a meaningful achievement for some individuals.

  • See also:

Glycaemic targets

  • HbA1c target – individualise according to patient circumstances. Generally ≤ 7.0% (53 mmol/mol).

    • Goals may be lower (6.5%) in patients:

      • without overt cardiovascular disease.

      • with a shorter duration of the disease.

      • on controlled diets.

      • on treatment with low risk of hypoglycaemia (metformin, DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 agonists). See Diabetes Medications.

      • with a lower baseline HbA1c.

    • Goals may be higher in patients who:

      • are aged > 65 years.

      • have co-morbidities.

      • are at risk of adverse drug effects e.g., hypoglycaemia causing confusion, falls and fractures, renal dysfunction, alcoholism.

    • Discuss the BGL goals with patients as they may vary according to:

      • risk of hypoglycaemia (e.g., frail or elderly), or impairment of quality of life.

      • presence of pre-existing cardiovascular disease or other high-risk factors e.g., hypertension, dyslipidaemia.

  • Blood glucose goals – individualise according to patient circumstances. Generally:

    • 5 to 7 mmol/L fasting.

    • < 10 mmol/L post-prandial.

Glycaemic management

  • Seek urgent diabetes specialist assessment if:

    • persistent or severe hyperglycaemia (> 20 mmol/L).

    • HbA1c > 97 mmol/mol (11%).

    • presence of ketonuria or ketonaemia (> 0.6 mmol/L).

  • For all other patients – if the patient is:

  • If medication is required:

    • Metformin is first-line unless contraindicated or not tolerated, even if not overweight.

      • Start with low dose (e.g. 500 mg daily) to reduce gastrointestinal intolerance.

      • Titrate to maximum tolerated dose within 2 to 3 months.

    • Second-line agents may be necessary and should be chosen using an individualised approach. See Diabetes Medication.

  • Monitor HbA1C:

    • every 3 months if glycaemic targets not met or following treatment changes.

    • every 6 months if glycaemic targets achieved.

Monitor blood glucose if clinically indicated

Screening

Arrange appropriate monitoring and screening as per chronic disease management plan (Medicare provides specific item numbers). Offer patients a diabetes management record card.

Immunisations

Other considerations and supports:

  • Consider fitness to drive.

    Fitness to drive

    • Hypoglycaemia, lack of hypoglycaemia awareness, complications such as CV disease, retinopathy, neuropathy and foot problems can affect fitness to drive.

    • Patients should be advised of the effects of their condition on driving, and advised of their legal obligation to notify the driver licensing authority when driving is likely to be affected.

    • Under AustRoads guidelines, commercial drivers must be reviewed annually by a diabetes specialist.

    • For detailed information, refer to AustRoads – Assessing Fitness to Drive.

  • Complete NDSS registration to reduce cost for diabetes products, and allow access to additional resources. Patients receive a starter pack on registration.

    NDSS registration

    NDSS registration forms are available either:

  • Consider recalls for regular follow up.